Primary Health Networks Core Funding
Primary Health Networks After Hours Funding
Activity Work Plan 2016-2018
Eastern Melbourne Primary Health Network
Operational & Flexible Funding
Activity Work Plan
2 | PHN Core Funding, PHN After Hours Funding
Introduction
Overview
The key objectives of Primary Health Networks
(PHN) are:
• I ncreasing the efficiency and effectiveness
of medical services for patients, particularly
those at risk of poor health outcomes; and
• I mproving coordination of care to ensure
patients receive the right care in the right
place at the right time.
Each PHN must make informed choices about
how best to use its resources to achieve these
objectives.
Together with the PHN Needs Assessment
and the PHN Performance Framework, Eastern
Melbourne PHN has outlined activities and
measurable performance indicators to provide the
Australian Government and the Australian public
with visibility as to the activities of our PHN.
This document, the Activity Work Plan
template, captures those activities.
This Activity Work Plan covers the period from
1 July 2016 to 30 June 2018. To assist with PHN
planning, each activity nominated in this work
plan can be proposed for a period of 12 months
or 24 months. Regardless of the proposed
duration for each activity, the Department of
Health will still require the submission of a
new or updated Activity Work Plan for 2017-18.
The Activity Work Plan template has the
following parts:
1. T
he Core Funding Annual Plan 2016-2018
which will provide:
a) The strategic vision of each PHN.
b) A
description of planned activities funded
by the flexible funding stream under the
Schedule – Primary Health Networks
Core Funding.
c) A
description of planned general practice
support activities funded by the operational
funding stream under the Schedule –
Primary Health Networks Core Funding.
2. T
he After Hours Primary Care Funding Annual
Plan 2016-2017 which will provide:
a) T
he strategic vision of each PHN for
achieving the After Hours key objectives.
b) A
description of planned activities
funded under the Schedule – Primary
Health Networks After Hours Primary
Care Funding.
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4 | PHN Core Funding, PHN After Hours Funding
Annual Plan 2016-2018
Annual plans for 2016-2018 intend to:
• p
rovide a coherent guide for PHNs to
demonstrate to their communities, general
practices, health service organisations,
state and territory health services and the
Commonwealth Government about what the
PHN is going to achieve (through performance
indicator targets) and how the PHN plans to
achieve these targets;
• b
e developed in consultation with local
communities, Clinical Councils, Community
Advisory Committees, state/territory
governments and Local Hospital Networks
as appropriate; and
• a
rticulate a set of activities that each
PHN will undertake, using the PHN Needs
Assessment as evidence, as well as identifying
clear and measurable performance indicators
and targets to demonstrate improvements.
Activity Planning
The PHN Needs Assessment has identified local
priorities which in turn informs and guides the
activities nominated for action in the 2016-2018
Annual Plan.
Primary Health Networks
After Hours Funding
From 2016-17, PHNs will have greater flexibility
to commission programme specific services,
having completed needs assessments for their
regions and associated population health
planning. PHNs are funded to address gaps in
after hours service provision and improve service
integration within their PHN region.
Measuring Improvements
to the Health System
National headline performance indicators, as
outlined in the PHN Performance Framework,
represent the Australian Government’s national
health priorities.
In addition, Eastern Melbourne PHN has identified
local performance indicators to demonstrate
improvements resulting from the activities we
are undertaking. These will be reported through
the six and twelve month reports and published
as outlined in the PHN Performance Framework.
Activity Work Plan Reporting Period
and Public Accessibility
The Activity Work Plan will cover the period 1 July
2016 to 30 June 2018. A review of the Activity Work
Plan will be undertaken in 2017 and resubmitted
as required under Item F.22 of the PHN Core
Funding Agreement between the Commonwealth
and all Primary Health Networks.
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6 | PHN Core Funding, PHN After Hours Funding
EMPHN Operating Model and the
Commissioning Framework
Commissioning Framework
In its role as a facilitator of primary care
system improvement and redesign, EMPHN
has adopted an operating model made up
of a continuous improvement approach to
commissioning, and governance structures
geared towards collaboration and co-design.
Our commissioning process
Commissioning is a cycle. Needs are assessed
through community consultation and solutions
are designed in partnership with stakeholders.
Transparent processes are used to promote the
implementation of these solutions, including the
identification of providers from whom services
may be purchased. Solutions are then evaluated
and the outcomes used to further assessment
DRAFT
and planning.
for discussion only
Activity
Establish stakeholders and targets for durable
improvements
Establish sequence of authorisation / permissions
and action these
Influence local system reform
Outputs
MOUs / agreements / authorisations
Project level documentation i.e., A3s
Activity
Quantitative evaluation against
metrics
Qualitative evaluation on
experiential factors
Embed
change
Translate / disseminate findings
Determine and recommend
adoption of new processes
Activity
Identify gap between current and
desired state
Confirm nature of problem (quality /
cost / flow)
Identify related issues & indicators
Determine characteristics / scope of
problem
Outputs
Problem
definition
Brief: scope / benefits / costs / timeline
Team structure: governance / sponsors
/ role
Project plan, including engagement /
measurement
Outputs
Activity
Evaluation reports
Evaluate
Future recommendations
Evidence publications
Diagnostics
Gather available data (demand /
capacity / consumer voice) and/or
develop data collection tools
Identify current state (process, issues /
waste)
Analyse issues (fishbone) and identify
root cause
Activity
Invite bids and evaluate
submissions against criteria
Deliver
Refine design with potential
providers
Select and contract providers
Outputs
Solution
Design
Current state map
Root cause analysis with hypotheses
(If x, then y)
Integrate local services / pathways
Outputs
Service delivery contracts
Care Pathways
Implementation reports
Performance reports
Activity
Understand sector landscape
Co-design service models / service improvements
Capacity building and sector development
Figure 1. Commissioning cycle
Outputs
Commissioning
specifications
Core Functions are
to facilitate
Differentiation
Envisioning
with rigour
Analysing
Delivering
addressable
Effect
"what
& continuously
improve
Underpinning the phases of the Commissioning
Cycle is a focus on ongoing relationships with
consumers, providers and other stakeholders.
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Figure 2. Prioritisation approach
Commissioning principles
1. U
nderstand the needs of the community by
engaging and consulting with consumer, carer
and provider representatives, peak bodies,
community organisations and other funders.
2. Engage potential service providers well in
advance of commissioning new services.
3. Focus on outcomes rather than service models
or types of interventions.
4. Adopt a whole of system approach to meeting
health needs and delivering improved health
outcomes.
5. Understand the fullest practical range of
providers including the contribution they
could make to delivering outcomes and
addressing market failures and gaps.
6. Co-design solutions; engage with stakeholders,
including consumer representatives, peak
bodies, community organisations, potential
providers and other funders to develop
outcome focused solutions.
8 | PHN Core Funding, PHN After Hours Funding
7. C
onsider investing in the capacity of
providers and consumers, particularly
in relation to hard to reach groups.
8. E
nsure procurement and contracting
processes are transparent and fair,
facilitating the involvement of the broadest
range of suppliers, including alternative
arrangements such as consortia building
where appropriate.
9. M
anage through relationships; work in
partnership, building connections at multiple
levels of partner organisations and facilitate
links between stakeholders.
10. Ensure efficiency and value for money.
11. M
onitor and evaluate through regular
performance reporting, consumer,
community and provider feedback
and independent evaluation.
Consultative structures
The EMPHN Board will receive strategic advice on engagement and participation from to key groups:
How we achieve our vision via our collaborations,
DRAFT
for discussion only
strategy
and
our business
•our
Community
Advisory
Committee
Evaluation
per
investment
Priority
Working Groups
Connect with endusers and implement
MANAGERS
CONTENT &
IMPROVEMENT
EXPERTS
Integration
Groups
Align and allocate
resources
STRATEGISTS
A
better
PHC
system
Governance
Groups
Direct and
authorise
BETTER
VISION
• Clinical Council
Leaders commit to system improvement
Joint forecasting and planning occurs
1-
O utco m es and evidence are translated into action
Committed
Leaders
BETTER
SYSTEM
ACTION
EVIDENCE
ACTION
EVIDENCE
ACTION
EVIDENCE
Inno vatio n & change capacity is enhanced
Investment decisions are targeted for highest impact
2-
Consumers and providers (including GPs) are engaged
Service needs are prioritised and identified gaps are filled
Investment
Decisions
Improvement proposals are based on best evidence
Care processes reflect need and employ
best use of resources
3-
Design and re-design occurs collaboratively
Services are reoriented to better meet needs
Care
Processes
Patients know where to go, when and why
Effective, efficient services are procured
STRATEGY
COLLABORATIVE STRUCTURE
Figure 2. Collaborative Structures
4-
VALUES
Leadership • Understanding
Collaboration • Outcomes
OUTCOMES
EXPERIENCE
ACCESS
An organisation that
delivers on its promise
The EMPHN catchment will be divided into four
sub-catchments for the purposes of shared
planning and governance. The sub-catchments
will align with the large public health services
in the catchment:
• Austin Health
• Eastern Health
• Monash Health
• Northern Health
Each sub-catchment will have three levels
of collaborative structures:
1. G
overnance Group: Strategists who "direct
and authorise"
BUSINESS PLAN
Capable, responsive people
Stewardship of commissioned funds
Collaborative governance mechanisms
Engaged communities
Change & improvement methodologies
Internal structures
ACTION
EVIDENCE
Robust, shared data
Innovative research partnerships
The EMPHN organisational structure includes
programs that support and develop primary care
practitioners, and that support primary care
improvement and integration.
In addition to the formal governance structure,
EMPHN staff work across teams within specialty
area streams such as Indigenous Health, Aged
Care, Refugee Health and Mental Health.
EMPHN staff also work across teams to
participate in improvement and innovation
initiatives.
2. H
ealth System Integration Group: Managers
who "align and allocate resources"
3. P
riority Working Groups: Content experts
who "connect with end users and implement"
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1. (b) Planned activities funded by the flexible funding
stream under the Schedule – Primary Health Networks
Core Funding
PHNs must use the table below to outline the activities proposed to be undertaken within the period 2016-18. These activities will be funded under the
Flexible Funding stream under the Schedule – Primary Health Networks Core Funding.
Note 1: Please copy and complete the table as many times as necessary to report on each activity.
Note 2: Indicate within the duration section of the table if the activity relates to a two year period (2016-2018) or a one year period (2016-2017).
Proposed Activities
Priority Area (e.g. 1, 2, 3)
1. Avoidable hospital admissions from Ambulatory Care Sensitive Conditions (ACSCs).
NP1: Avoidable hospital admissions from Ambulatory Care Sensitive Conditions
NP1.1 Establish collaborative structures
Activity Title / Reference (e.g. NP 1.1)
NP1.2 Deeper dive into sub-catchment experience of preventable admissions
NP1.3 Co-design and delivery ofsolutions to reduce preventable admissions
NP1.4 Review and extrapolate findings of pilot to high risk ACSCs.
Description of Activity
The following activities will be undertaken to look at innovative and collaborative cross-system
approaches to addressing potentially avoidable hospitalisations.
In recognition of diabetes complications being the clear front runner for Ambulatory Care Sensitive
Conditions, activities will commence with diabetes as the pilot model:
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1.1 Establish collaborative governance structure in the outer north, the north east and the east.
1.2 Deeper dive into each sub-catchment including:
a) Population health data
b) Service mapping
c) Community attitudes
d) Clinician attitudes
1.3 Co-design and deliver solutions based on findings, including:
- Service development
- Clinician engagement and resources including clear referral pathways (i.e.
HealthPathways)
- Community engagement and resources including community mobilisation / activation,
health literacy, health system / pathway knowledge
1.4
Review and consider extrapolation for other high risk ACSCs.
Cross reference: Activity NP2.7 Trialling of predictive modelling, risk stratification to reduce avoidable
hospitalisation.
Undertaken in collaboration with:
•
Collaboration
Duration
•
Service users – such as community members with chronic illness and mental health clients as
per demographic findings of Activity 1.1)
Local Health Networks (LHNs), Community Health Services (CHSs), Primary Care Partnerships
(PCPs), GP representation via focus groups, EMPHN advisory groups: Clinical Council (CC),
Community Advisory Group (CAG).
Activities 1.1 – 1.3 July 2016- June 2017
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Activity 1.4 July 2017 – June 2018
Coverage
Entire PHN region, however may be refined according to the findings of 1.1 and 1.2.
Activities will follow the EMPHN Commissioning process outlined in section 1a, to include:
Problem Definition, Diagnostics, Solution Design, Delivery, Evaluation and Embedding Change.
Commissioning approach
The current activities listed fit within the Problem Definition to Solution Design components of the
methodology. The solutions may require procurement of services for Delivery and appropriate
options for procurement will be assessed at that time and advised to the Department.
Where services are purchased – such as the delivery of an education campaign jointly purchased with
partners – a clear brief will be developed and performance metrics built into contracts.
1.1 Establish for each collaborative: (Output)
• Shared objectives and work plan
• Shared current state picture
• Work specifications / commissioning specifications
• Deliverable programs of work, e.g. service contracts, resources developed
Performance Indicator
(Process, Output or Outcome indicator)
1.2
Deeper dive tabled with Collaborative Platforms to share data and develop a deeper
understanding of populations affected (Process)
1.3 a) Solutions designed to target the early intervention of diabetes and reducing acuity of diabetes
complications in the EMPHN population (Process)
b) Reduction in hospital ACSC admissions and bed days for diabetes (Outcome)
1.4 Lessons learned documented for application to hypertension and/or pyelonephritis (Process).
1.1 Collaborative Structure and working groups established
Local Performance Indicator target
1.2 Co-authored reports with recommendations developed
1.3 a) Plan developed
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1.3 b) Reduction in avoidable diabetes complications as a proportion of hospital admissions
(reviewed according to LGA, gender and age)
1.4 Lessons learned and recommendations developed for extrapolation to further ACSCs
1.1 Collaborative structure meeting minutes
Data source
1.2 Planning drafting
1.3 a) planning drafting
1.3 b) VEAD Dataset (Victorian)
1.4 Evaluation findings
Proposed Activities
Priority Area (e.g. 1, 2, 3)
2 Reducing ED presentations for primary care type conditions
NP2: Reducing ED presentations for primary care type conditions
NP2.1 ED presentation population data deeper dive
NP2.2 Data review of ED presentation drivers
Activity Title / Reference (e.g. NP 1.1)
NP2.3 Support for eReferral and My Health Record uptake
NP2.4 Alternative care option community education
NP2.5 HealthPathways support to increase primary care capacity to reduce ED presentations
NP2.6 Co-design and delivery of pilot programs to reduce ACSCs presenting to ED
NP2.7 Supporting testing of POLAR DIVERSION Risk Algorithm
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The following activities will be undertaken to ensure a deeper understanding of the drivers of ED
presentations for Category 4 & 5 conditions and develop a collaborative, cross-system approach to
addressing potentially avoidable hospital use.
2.1 Agreeing on the problem: Deeper dive with collaborators into available data to develop shared
understanding and determine what can be learned about complexities, specific issues,
demographics and localities, and relationships between them, to support targeted projects (see 1,
3, 4).
2.2 Collaborate with academic research centres to validate and prioritise to address localised drivers
for ED presentations e.g. attitudinal beliefs about cost, perception of workforce capacity
(especially paediatrics) and convenience (key factors known to be driving some ED presentations
for Category 4 & 5 conditions).
Description of Activity
2.3 Support for the use of eReferral and uptake of My Health Record within the region.
2.4 Collaborate with academic institutions, PCPs, LHNs to develop a regional plan for communicating
to the public their care options and health behaviour change messages.
2.5 Improve system navigation knowledge for GPs and other primary care providers--expand and
promote access to HealthPathways, addressing identified need of part-time, low experience and
locum GPs for system pathways and referral information.
2.6 Based on 2.4 (above), co-design specific issue pilot programs aimed at reducing ACSCs presenting
to ED and pilot these in key target locales.
Examples:
• Support GPs and practices to manage more target area low acuity and paediatric
consultations with specialty education and programs to trial in-practice nurse practitioners.
• Investigation of procuring additional diagnostic support for General Practice, so that
referral to ED is not necessary.
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•
•
Investigate trialling a specialist hotline for use by GPs.
Co-develop process and outcome measures specific to determining wins, gaps and
learnings from the pilots.
2.7 Partner to validate within general practice the POLAR Diversion project to address GP capacity to
prevent avoidable ED presentations by brokering test general practice sites to validate the
algorithm and provide input on the reporting process. POLAR Diversion is an algorithm of risk
which will be trialled in general practice by analysing their data to highlight a report of at-risk
patients and presenting that report to General Practice to validate based on clinical opinion.
Activities will be undertaken in collaboration with the following:
•
Collaboration
•
•
Service users—such as parents of children 0-5 years, mental health clients of low acuity
(general practice type presentations) as per demographic findings of Activity 1.
Local Health Networks (LHNs), Community Health Services (CHSs), Primary Care Partnerships
(PCPs), GP representation via focus groups, EMPHN advisory groups: Clinical Council (CC),
Community Advisory Group (CAG)
Universities, via partnerships with their research centres, e.g. Deakin Faculty of Health (6
research centres [e.g. SEED for youth AOD], +/- health economist.
Anticipated activity start and completion dates (excluding the planning and procurement cycle):
Duration
Activities 2.1 – 2.2 to commence 1st July 2016 – 30th June 17
Activity 2.3 1st July 2016 - ongoing
Activities 2.3- 2.6 to comment 1st October 2016 to 20th June 2018.
Coverage
Entire EMPHN region.
Commissioning approach
Activities will follow the EMPHN Commissioning process outlined in section 1a, to include:
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Problem Definition, Diagnostics, Solution Design, Delivery, Evaluation and Embedding Change.
The current activities listed fit within the Problem Definition to Solution Design components of the
methodology. The solutions may require procurement of services for Delivery and appropriate options
for procurement will be assessed at that time and advised to the Department.
Where services are purchased – such as the delivery of an education campaign jointly purchased with
partners – a clear brief will be developed and performance metrics built into contracts.
2.1 Deeper dive tabled with Collaborative Platforms to share data and develop a deeper
understanding of populations affected (Process)
2.2 Agreed drivers to address via 2.6 (Output)
2.3a Communication plan developed in partnership with stakeholders addressing drivers of ED
presentations in relation to populations at higher risk (Output)
2.3b Post-campaign analysis of metrics to determine reach (Outcome)
Performance Indicator
(Process, Output, Outcome)
2.3 c Decreased Category 4 & 5 ED presentations as a proportion of total presentations (Outcome)
2.4 Issue of new pathways for outstanding ACSCs and Mental Health, with focus on options for outer
regions (Output)
2.5 Pilot programs designed with consumers and stakeholders as innovative approaches to reduce ED
admissions (Process)
2.6 a) Partnership developed to trial algorithm and report within practices in the region (Output)
b) Successful engagement of agreed number of practices (estimated 20) with feedback regarding
the accuracy of the algorithm and suitability of the reporting process (Process).
Local Performance Indicator target
2.1 Working group established
2.2 Co-authored reports with recommendations developed
2.3 a) Plan released
b) Post campaign analysis of metrics determine
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c) 10% proportional decrease in Category 4 & 5 ED presentations for campaign target group from
baseline
2.4 Issue of new Health Pathways for outstanding ACSCs, Mental Health, with focus on options for
outer regions
2.5 Dependent on nature of project brief for 2.4
2.6 a) MOU developed with MEGPN to partner in the trial of the algorithm
b) Trial undertaken with agreed number of practices and feedback provided to MEGPN.
2.1 Collaborative/Working group meeting minutes
2.2 Report drafting
2.3 a) Planning drafting
b) Metrics associated with method of campaign (social media, local media distribution, etc)
Data source
c) VAED data via POLAR – disaggregated by gender, location, RACF and Business Hours vs After
Hours
2.4 Health Pathways developed and metrics of use reported
2.5 Planning drafting
2.6 a) MOU document
b) Trial monitoring
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Proposed Activities
Priority Area (e.g. 1, 2, 3)
3
Integrated Care for Chronic Disease Prevention & Management
NP3: Integrated care for Chronic Disease Prevention & Management
NP3.1 Roll-out of a Clinical Audit Tool in general practice for Chronic Disease patient population
auditing
NP3.2 Develop a deeper understanding of a proposed Patient-Centred Healthcare Home Model
NP3.3 Commissioning of self-management programs based on evidence
Activity Title / Reference (e.g. NP 1.1)
NP3.4 Review of Chronic Disease Health Pathways according to chronic diseases experienced in the
EMPHN population
NP3.5 Increasing uptake of ePIP, eReferral and My Health Record in the EMPHN region
NP3.6 Workforce supports for culturally safe practice in primary care
NP3.7 Chronic Disease CPD
Description of Activity
A multifaceted approach to chronic disease management will be applied with this suite of activities.
This includes working with general practice to build data quality and a population profile of service use
in general practice and quality of care in reaching clinical outcomes, developing innovative models
with consumers and stakeholders for chronic disease care, ensuring adequate workforce supports
through education, eHealth support and Health Pathways and the procurement of services to increase
capacity for prevention and early intervention in our region. These activities include:
3.1 Roll-out of POLAR within general practice for internal clinical auditing of chronic disease of the
practice patient population
3.2 Development of a proposed model for the Patient Centred Healthcare Home
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3.3 Procurement of self-management programs based upon best evidence of existing successful
models and innovative approaches
3.4 Review/audit of the current HealthPathways developed relating to chronic disease emerging from
data
3.5 Workforce supports for culturally safe practice to primary care designed with input from providers
and consumers for CALD and ATSI consumers ***Support to Indigenous Australian’s Program
Activity Workplan
3.6 Chronic Disease continued professional development in line with emerging chronic conditions
(Hepatitis B, Diabetes, Asthma, COPD)
Collaboration
Indigenous Specific
Activities will be undertaken in consultation and collaboration with Hospitals, CHSs, PCPs,
[Collaborative Platforms], peak bodies, VicHealth, consumers, GPs, practice staff, pharmacist, allied
health, specialists, RACFs, [disability / youth / homeless / CALD services], carers, private health
insurance, community nursing, MEGPN.
Is this activity targeted to, or predominantly supporting, Aboriginal and Torres Strait Islander people?
(YES/NO)
No – but considered within scope as a target group for activities.
Duration
3.1
3.2
3.3
3.4
3.5
3.6
July 2016 onwards
August 2016 – February 2017
February 2017 – June 2018
July 2016 – June 2017
July 2016 – June 2017
July 2016 – June 2018
Coverage
Entire EMPHN region
Commissioning approach
Activities will follow the EMPHN Commissioning process outlined in section 1a, to include:
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Problem Definition, Diagnostics, Solution Design, Delivery, Evaluation and Embedding Change.
The current activities listed fit within the Problem Definition to Solution Design components of the
methodology. The solutions may require procurement of services for Delivery and appropriate options
for procurement will be assessed at that time and advised to the Department.
Where services are purchased – such as the delivery of self management and health promotion
programs – a clear brief will be developed and performance metrics built into contracts.
3.1 a) Number of practices participating in data quality program (Process)
b) Improved data quality within General Practice through quality improvement visits by GP
Improvement and Integration Facilitators (Outcome)
3.2 Proposed Patient Centred Health Care Home developed in consultation with consumers and
clinicians (Output)
Performance Indicator
3.3 Procurement of self management program/s that provide evidence of reach, effectiveness and
efficacy through agreed performance measures that will include number of referrals received,
patient participation, drop-out profile, completion, patient experience and clinical outcomes
(Process to lead to Outcome measures in evaluation).
3.4 Current pathways reviewed for coverage of chronic disease profile of the region with planning
underway for remaining topics (Output)
3.5 Workforce supports developed, with input from consumers and clinicians (Output)
3.6 a) CPD calendar planning includes condition specific training in consultation with General Practice
and subject matter experts (Output)
b) Improved clinician knowledge and confidence to address chronic disease identification, early
intervention and prevention within General Practice (Outcome)
3.1 Total 70 practices (currently 0) in the region with POLAR GP by 30th June 2018
Local Performance Indicator target
3.2 Proposed Patient Centred Medical Home developed in consultation with consumers and clinicians
and based upon local and international evidence
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3.3 Performance metrics to be set with provider, however evidence of and/or improvement sought
across the areas of; number of referrals received, Patient participation, drop-out profile,
completion, patient experience and clinical outcomes.
3.4 Pathways developed, or planned to be developed, for key chronic diseases experienced by the
EMPHN population including; Type 2 Diabetes, Obesity, Hepatitis B & C, Bone & Joint Disease and
Respiratory Disorders
3.5 Workforce supports developed and determined by those consulted to meet the needs of the
community and clinicians (who are undertaking the training)
3.6 a) CPD calendar planning incorporates training with learning objectives related to identified deficits
in clinician skillsets
b) Improved self-reported knowledge and confidence compared to pre-training to address
chronic disease identification, early intervention and prevention within general practice
3.1 EMPHN CRM tracking
3.2 Planning drafting
3.3 Commissioning Process and Evaluation findings
Data source
3.4 Health Pathways metrics
3.5 Support materials
3.6 a) Number of GPs / practices participating
b) Improved self-reported competency on evaluation forms
3.7 Commissioning process and evaluation findings.
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Proposed Activities
Priority Area (e.g. 1, 2, 3)
4 Healthy Ageing
NP4: Ageing
NP4.1 Increasing telehealth capacity for Urology, Geriatrics and Endocrinology
NP4.2 Interim Medication Improvement Project with LHNs
Activity Title / Reference (e.g. NP 1.1)
NP4.3 Develop Palliative Care Health Pathways
NP4.4 QUM rollout with focus on polypharmacy and falls, and antibiotic resistance
NP 4.5 Review evidence of falls prevention approaches for recommendations for action
NP 4.6 Review evidence on reducing polypharmacy/de-prescribing and develop recommendations
NP 4.7 Early Intervention Model for healthy ageing
Healthy ageing is a key issue for the EMPHN region with a high number of RACF beds and an ageing
population, particularly in the inner, more densely populated areas. Activities to support healthy
ageing have a natural overlap with avoiding hospital presentations by seeking to: increase quality of
life and reduce acuity, improve service coordination and information, support general practice
through Health Pathways and innovative models of early intervention, and increased access to
services, including specialist telehealth. Activity includes:
Description of Activity
4.1 Supporting increased telehealth capacity within the specialties of urology, geriatrics and
endocrinology
4.2 Interim Medication Chart improvement projects with LHNs
4.3 Undertake to develop Palliative Care Health Pathways and promote to general practice and
locums
4.4 Quality Use of Medicines program roll-out with a particular focus on polypharmacy and antibiotic
resistance
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4.5 Review findings of current falls programs and Benetas Frailty Research Project to determine
recommendations of action to address frailty and falls.
4.6 Review current research and models of care regarding de-prescribing and reducing polypharmacy
in older populations.
4.7 Develop a model of early intervention for healthy ageing at 45-49 year-old health check to 75
year-old health check to promote healthy ageing and decreased risk of chronic disease, including
consideration of commissioning cardiologist access to general practice for ongoing monitoring of
patients at risk of heart failure and commissioning community education in the Whittlesea/Wallan
region regarding heart health.
Activities to be undertaken with the following stakeholders:
Collaboration
Indigenous Specific
Northern Hospital and other LHNs, in-reach services, specialists, palliative care services, pharmacies
(supply and community), general practice, RACFs, allied health, local councils, Council of the Ageing,
Benetas, Heart Foundation, Community Health Services
Is this activity targeted to, or predominantly supporting, Aboriginal and Torres Strait Islander people?
No
4.1 July 2016 – June 2018
4.2 November 2016 – June 2018
4.3 July 2016 – June 2017
Duration
4.4 August 2016 –June 2018
4.5 November 2016 – November 2017
4.6 September 2016 – September 2017
4.7 August 2016 – June 2018
Coverage
Commissioning approach
Entire EMPHN region, with a particular focus on the Northern and Austin LHN catchments
Activities will follow the EMPHN Commissioning process outlined in section 1a, to include:
Problem Definition, Diagnostics, Solution Design, Delivery, Evaluation and Embedding Change.
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The current activities listed fit within the Problem Definition to Solution Design components of the
methodology. The solutions may require procurement of services for Delivery and appropriate
options for procurement will be assessed at that time and advised to the Department.
Performance Indicator
4.1 Increased number of urology, geriatric and endocrinology services that have telehealth capacity
across the region
4.2 Plan established with Public LHNs to undertake an Interim Medication Chart Improvement Project
based upon prior learnings of MLs
4.3 Pathways designed with relevant stakeholders, including feedback from community palliative care
providers
4.4 Improved provider confidence and knowledge in reducing polypharmacy and antibiotic resistance
4.5 Review paper and recommendations developed to inform future action regarding falls prevention
4.6 Review paper and recommendations developed to inform future action regarding de-prescribing
4.7 Proposed model developed for early intervention of key ageing issues with activation of
monitoring post 45-49 year-old health check to prevent and reduce burden of disease.
4.1 Total 24 consultations supported resulting a $ target saving achieved though avoided patient
transfers
4.2 Plan developed in consultation with LHNs, GPs, RACFs and locums
Local Performance Indicator target
4.3 Palliative Care Pathways designed with subject matter expertise and demonstration of uptake
within first 3 months of launch
4.4 20% improvement from pre-training intervention scores
4.5 Review paper developed with local and international findings and shared with appropriate
network/Collaborative Platform
4.6 Review paper developed with local and international findings and shared with appropriate
network/Collaborative Platform
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4.7 Model developed and prepared for trial.
4.1 MBS telehealth consultations
4.2 Plan Drafting
4.3 Pathways developed and Health Pathways Melbourne usage metrics
Data source
4.4 Provider pre- and post-assessment from in-practice education
4.5 Review paper development
4.6 Review paper development
4.7 Model drafting
Priority 5: Culturally appropriate care for Aboriginal & Torres Strait Islander Communities will be addressed through the Indigenous Australians Program
Activity Work Plan
Proposed Activities
Priority Area (e.g. 1, 2, 3)
6 Access to Care for Refugee and CALD Communities
LP6: Access to Care for Refugee and CALD Communities
Activity Title / Reference (e.g. NP 1.1)
LP6.1 Support to general practice in better use of interpreters
LP6.2 Workforce awareness and preparation to support refugees with a disability
LP6.3 Broker supports for CALD carers as per National Ageing and Aged Care Strategy
Description of Activity
As the EMPHN region contains a diverse population, and have existing communities of humanitarian
arrivals as well as more settlement incoming, the capacity to delivery culturally appropriate care to
engage these populations and address their needs will be key to addressing the increased risks of ill
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health. Activities will be a combination of equipping general practice to respond and working with
stakeholders to improve the patient experience for CALD and refugee populations. These include:
6.1. Supporting general practice in better use of interpreters (develop and disseminate in-practice
workflows to ensure interpreter bookings, etc.)
6.2. Raising awareness of humanitarian arrival ineligibility for the NDIS to GPs and developing and
providing alternative pathways of care
6.3. Supporting general practice services engaged in locating and assisting CALD carers facing cultural
and other barriers in accessing carer support services (as per National Ageing and Aged Care Strategy,
p. 2).
6.1. a) Work with interpreter services to establish availabilities, reach and contacts of interpreters
needed to address language group needs across catchment
b) engage with GPs to promote availabilities and benefits of booking interpreters
c) work with practice managers to support workflow processes that facilitate timely booking of
services
Collaboration
6.2. Work with GPs and practice managers directly in promoting awareness and ensuring they have
facility and capacity to cater to this population. Ensure HealthPathways offers potential referral
pathways and promote this HP with GPs.
6.3. Work with general practice to ensure linkage for their CALD carer patients to have access to
appropriate aged care services, CHSs, and CALD and refugee support groups and assist with
supporting access to available, culturally appropriate services.
Indigenous Specific
No
6.1 July 2016- June 2017
Duration
6.2 July 2016 – June 2018
6.3 January 2017 – June 2018
Coverage
6.1. Whole of catchment
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6.2. Whole of catchment, focus on northern growth corridor in Whittlesea catchment
6.3. Whole of catchment scan with focus on key areas likely to include older, overlaid with CALD,
demographic.
Activities will follow the EMPHN Commissioning process outlined in section 1a, to include:
Problem Definition, Diagnostics, Solution Design, Delivery, Evaluation and Embedding Change.
Commissioning approach
The current activities listed fit within the Problem Definition to Solution Design components of the
methodology. The solutions are expected to relate to core functions of general practice engagement
and participation in existing networks.
6.1. Materials Developed to support general practice to appropriately utilise interpreter services
(Output)
Performance Indicator
Post-intervention implementation of workflows in general practice to utilise interpreters as usual
practice for CALD patients (Outcome)
6.2. Dissemination of information GPs and alternative referral pathways identified (Process)
6.3. Opportunity to support carers scoped and appropriate commissioning response enacted (Process)
Agency engagement metrics, stakeholder feedback (Outcome)
6.1. Dissemination of information to general practice
Local Performance Indicator target
6.2. Raised awareness of appropriate care, referrals to appropriate care, access to appropriate care
6.3. Engagements via CRM, reporting feedback from stakeholder groups.
6.1 CRM interaction statistics
Data source
6.2 CRM interaction statistics
6.3 Meeting materials and commissioning process.
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Planned Expenditure 2016-2017 (GST exc.) to
match budget
$xx
Funding from other sources (e.g. private organisations, state and territory governments)
Proposed Activities
Priority Area (e.g. 1, 2, 3)
7. Immunisation
NP7: Immunisation
Activity Title / Reference (e.g. NP 1.1)
NP7.1 Improve suboptimal childhood immunisation rates (particularly Monash LGA)
NP7.2 Address myths associated with immunisation resulting in ideological conscientious objection
NP7.3 Support workforce to respond to demand generated by government immunisation initiatives.
Description of Activity
No LGA meets the aspirational childhood immunisation rate of 95%. With childhood immunisation
rates across the catchment running at 89.1-93.7% across one or other of the age 1, 2 and 5
immunisation bands, Monash is the standout area for low rates consistently across the three
immunisation milestones and presents a strategic target for improvement activities. Objection on
ideological grounds contributing more strongly in Yarra Ranges and Nillumbik LGAs rates presents a
further opportunity for improved immunisation coverage. Childhood immunisation activities below
centre around improvement of suboptimal rates in our region and equipping the primary care
workforce and partners to address common myths associated with conscientious objection on
ideological grounds.
7.1. To improve identified suboptimal immunisation rates across catchment, noting Monash as
standout, support:
• Targeted intervention in LGA and SLA areas with lower immunisation rates.
• Support to immunisation providers to maintain current levels.
• Deeper dive into levers at systemic and local areas to push immunisation rates towards 95%
• Work collaboratively with regional immunisation networks (Eastern and Northern)
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•
Work with other PHNs through VPHNA to address systemic immunisation issues ( e.g. cold
chain breach reporting).
7.2. To support addressing of ideological conscientious objection, particularly in Nillumbik and Yarra
Ranges and deeper dive into levers and drivers for parents deciding not to immunise, support:
• Environment scan for innovative models to address community views
• Capacity building for general practice in talking about conscientious objections.
7.3. To support providers to respond to demand generated by government initiatives (e.g. ‘no jab no
pay’, ‘no jab no play’) for improving immunisation rates, support
• Sector and community education re ‘No jab no pay’ policy and how to respond
• Capacity building and resources to support immunisation reconciliation.
Activities will be undertaken in collaboration with:
Collaboration
Indigenous Specific
GPs, practice nurses, Local Government (immunisation coordinators), parents and community, RCH
(communicable diseases and immunisation specialists), refugee settlement services, migrant resource
services, local media.
Is this activity targeted to, or predominantly supporting, Aboriginal and Torres Strait Islander people?
(YES/NO)
No
Anticipated activity start and completion dates (excluding the planning and procurement cycle).
7.1 a) October 2016 - June 2018
b) July 2016 - October 2016
Duration
c) July 2016 - June 2018
7.2 a) October 2016 - May 2017
b) October 2016 - June 2018
7.3 July 2016 - June 2017
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Coverage
Entire PHN Region with a particular focus in the following LGAs:
• Monash (increasing immunisation rates)
• Nillumbik and Yarra Ranges (reducing conscientious objection)
Activities will follow the EMPHN Commissioning process outlined in section 1a, to include:
Problem Definition, Diagnostics, Solution Design, Delivery, Evaluation and Embedding Change.
Commissioning approach
The current activities listed fit within the Problem Definition to Solution Design components of the
methodology. The solutions are expected to relate to core functions of general practice engagement
and participation in existing networks, however, if the need to commission activity is highlighted
through this work, a clear brief will be developed, the appropriate commissioning process will be
selected and undertaken and performance metrics built into contracts. Evaluation findings will be
reviewed and reported.
7.1. a) Capacity building/education uptake by General Practice (Process)
b) Briefing paper on systemic and local levers including GP to population ratio in areas of low
immunisation, % conscientious objectors and numbers of child humanitarian arrivals where
possible (output)
Performance Indicator
c) Childhood immunisation increases 1% per annum towards 95% per SA2 area, per age group
(outcome) Baseline: All LGAs at 1, 2 and 5 years are above 90%.
7.2 a) Resources and community engagement collateral developed with input from consumers,
council and GPs (Output)
b) % of conscientious objectors reduces by 0.5% in target areas of Nillumbik and Yarra Ranges
(Outcome 2 years)
Local Performance Indicator target
7.3. Capacity building for general practice to reconcile data for child humanitarian arrivals and
international immunisation is developed and disseminated to GPs (Process) .
7.1. a) Uptake of support in minimum 20 Monash-region general practices
b) Briefing paper developed to inform action
c) Increase of 1% childhood immunisation rate per SA2 area, per age group, per annum towards
95%.
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7.2. a) Resources and community engagement collateral developed with input from consumers,
council and GPs
b) 1% reduction in conscientious objectors by June 2018
7.3 Dissemination of reconciliation support materials via web, practice visits and email to all practices.
7.1 a) CRM interaction statistics
b) Briefing paper drafting
Data source
c) ACIR Dataset (compared to baseline)
7.2 a) Collateral materials
b) ACIR Dataset (compared to baseline)
7.3. a) Web click rate and CRM statistics.
Local Priority 8 will be undertaken by the Population Health team as standard business. In recognising that there are existing regional initiatives with strong
leadership by Women’s Health Organisations, the activities are limited to the sphere of influence of the PHN and working with the capacity of primary care
to respond and aim to compliment these regional initiatives.
Local Priority area 9 (screening for sexually transmitted infections) is dealt with under General Practice Engagement (OP 2)
Proposed Activities
Priority Area (e.g. 1, 2, 3)
Cancer Screening
Activity Title / Reference (e.g. NP 1.1)
NP10: Cancer Screening
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NP10.1 Partnership to develop GP Workforce Support Module and diverse community engagement
strategy
NP10.2 Reviewing expansion and capacity of peer support networks
NP10.3 Building capacity in General Practice for increased uptake of cancer screening in the
community.
Description of Activity
Collaboration
Indigenous Specific
Cancer screening for EMPHN will have a focus on general practice cancer screening rates. Activities
will be undertaken in collaboration with subject matter expertise from peak cancer organisations and
there may be replicability across PHN boundaries. Activities will work to increase capacity and raise
local cancer screening participation rates through:
10.1 Partnering with peak body organisations to develop :
A work package for roll out in General Practice to support increased cancer screening
A diverse community engagement strategy regarding the promotion of cancer screening
(CALD, Refugee & ATSI)
10.2 Review/expansion of current peer support networks for cancer survivorship
10.3 Capacity building in general practice through education, business and process modelling to
encourage a rigorous approach across the catchment for breast, bowel and cervical cancer screening.
Activities will be undertaken in collaboration with:
•
•
•
•
•
Peak cancer bodies
LHNs
PHN Alliance
Diverse Community Support Services
Department of Health (State/Federal)
Is this activity targeted to, or predominantly supporting, Aboriginal and Torres Strait Islander people?
(YES/NO)
Yes – Broader population approach however working with the Aboriginal Health team to increase
breast cancer screening rates in Aboriginal women in our community.
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Duration
10.1 July 2016 - April 2017
10.2 July 2016 -June 2018
10.3 April 2017 - June 2018.
Coverage
Entire EMPHN Region.
Activities will follow the EMPHN Commissioning process outlined in section 1a, to include:
Problem Definition, Diagnostics, Solution Design, Delivery, Evaluation and Embedding Change.
Commissioning approach
The current activities listed fit within the Problem Definition to Solution Design components of the
methodology. The solutions may require procurement of services for Delivery and appropriate
options for procurement will be assessed at that time and advised to the Department.
It is anticipated that activity 10.1 may highlight the need to commission services from a peak
organisation for the development of the package. Where services are purchased a clear brief will be
developed, the appropriate commissioning process will be identified and undertaken and
performance metrics built into contracts.
Process
Performance Indicator
10.1 Initial Project Plan developed with peak cancer organisations for:
- work package to deliver to General Practice to increase capacity for cancer screening
- diverse community engagement strategy and suite of resources for cancer screening
promotion
10.1 Evidence of key partners engaged
Outputs
10.1 Cancer screening work package developed by EMPHN collaboration with peak bodies and
stakeholders to deliver in practices.
10.2 Report on efficacy of current peer support networks and how PHN can better assist.
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Outcome
10.3 Aim to reach the following cancer screening rates by June 2018:
Bowel Cancer Screening 50%
Cervical Screening 75% for eligible women, with first year improvement
Breast Cancer Screening 75% for eligible women, with first year improvement of minimum 5% from
baseline per local government area
See also 9.6 regarding Hepatitis B & C
10.1 Project controls
10.2 Report created with peer network consultation with clear recommendations on PHN act
required
Local Performance Indicator target
10.3 Bowel cancer screening rates at 50%
Cervical Screening 75% for eligible women, with first year improvement
Breast cancer screening rates at 75% for eligible women, with first year improvement of minimum
5% from baseline per LGA.
10.1 Project controls
Data source
10.2 Report drafting
10.3 Cancer screening rates (ABS)
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1. Planned core activities funded by the operational
funding stream under the Schedule – Primary Health
Networks Core Funding
PHNs must use the table below to outline core activities (excluding administrative and governance related activities) funded under the Operational Funding
stream as described in section 1.5.1 of the PHN Grant Programme Guidelines.
Note 2: Indicate within the duration section of the table if the activity relates to a two year period (2016-2018) or a one year period (2016-2017).
Proposed activities
Activity Title / Reference (e.g. OP 1)
OP1: Population Health
The Population Health team has responsibility for equipping the organisation and its programs with:
-
Description of Activity
-
Continually updating needs assessments to inform program and commissioning activity in
health needs, service access trends, service mapping and forecasting
Undertaking deeper dives on issues to inform the organisations and its stakeholders it is
collaborating with
Providing the Collaborative Platforms with briefings of the key issues on which to focus
through the Collaborative Structure
Assisting and increasing the capacity of the organisation to source an evidence base and
appropriately evaluate projects and programs
This will ensure the organisation maintains a population health understanding of the health care
needs of the PHN communities through analysis and planning, knowing what services are
available and helping to identify and address service gaps where needed, including in rural and
remote areas, while getting value for money.
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A key assessed priority for the EMPHN catchment to be undertaking using the above responsibility
framework is that of the prevention of violence against women. The principle activity in relation
to that priority will be:
OP1.1 Active participation in our region in prevention of violence against women initiatives aimed at
reducing violence against women through planning, co-design and supportive activities. The initiatives
will be led by Women’s Health East and Women’s Health in the North.
Collaboration
This activity will be primarily internal capacity building and assist with our collaborative arrangements.
Collaboration on Prevention of violence against women activities will be via regional networks
currently led by Women’s Health East and Women’s Health in the North and where appropriate,
consultation with General Practice and Victims of Violence via Women’s Health East Speaking Out
Program
Duration
Ongoing. In respect of Prevention of violence activities, the anticipated activity start and completion
dates (excluding the planning and procurement cycle) are: July 2016-June 2017.
Coverage
Entire EMPHN region
Expected Outcome
Activities are expected to assist in achieving the following EMPHN Strategic Objectives:
1. Leaders commit to system improvement
1a. Joint forecasting and planning occurs
1b. Investment decisions are targeted for highest impact
2. Investment decisions are targeted for highest impact
2c. Improvement proposals are based on best evidence
3. Care processes designed for need and best use of resources
3b. Services are reoriented to better meet needs
3d. Effective, efficient services are procured
With regard to OP1.1, the EMPHN Population Health team will attend a minimum of 90% of Regional
Network meetings and demonstrate participation by the inclusion of actions within regional plans
relating to General Practice engagement and workforce development in prevention of violence
against women/family violence.
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PHN objectives:
The organisation maintains a population health understanding the health care needs of the PHN
communities through analysis and planning, knowing what services are available and helping to
identify and address service gaps where needed, including in rural and remote areas, while getting
value for money.
Proposed general practice support activities
Activity Title / Reference (e.g. OP 1)
OP2: General Practice Engagement & Support
EMPHN aims to provide support to General Practice to enable a better primary health care system
and ensure the programs and projects of EMPHN have strong engagement with General Practice.
General Practice Engagement is split into two key functions for EMPHN:
Description of Activity
General Practice Engagement –by taking a development approach to a caseload of practices,
deliver high quality education and support packages, in the areas of practice management,
practice nursing, vaccine management and immunisation, data quality, MBS, clinical software
and accreditation This includes delivery of in-practice education on a range of topics relevant
to both the identified priorities and the needs of general practice and supporting practices in
quality improvement activities to improve primary health care outcomes based on the
available data collection.
- General Practice Improvement & Integration- assisting with the development and
implementation of innovative activities, integrated with other program areas, which will
support general practice in adding value to and enhancing their clinics. Practice grants
program to achieve demonstration sites for the practice of the future “practice 2020”
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These teams will work in collaboration with programs across the organisation and maintain strong
connections with General Practice in our region. Whilst activities of support will look to address the
priorities identified in the needs assessment, they will also look to support the emerging workforce
development needs of General Practice and work closely with the Workforce Development and
Education team to inform calendars of activity.
This activity will support PHN objectives through: Supporting general practices in attaining the highest
standards in safety and quality through showcasing and disseminating research and evidence of best
practice. This includes collecting and reporting data to support continuous improvement;
providing practice support services so that GPs are better placed to provide care to patients
subsidised through the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS),
and help patients to avoid having to go to emergency departments or being admitted to hospital for
conditions that can be effectively managed outside of hospitals.
General Practice Engagement activities relate to a range of Flexible Fund activities. In addition, the
priority identified in the needs assessment of sexually transmitted infections will be incorporated into
the daily functions of the engagement team. STIs represent an area in which solid gains can be made
in ensuring adequate screening in our region and enabling its monitoring through notification data. An
identified local need, regional initiatives are underway in the North and East regarding sexual and
reproductive health on which there are platforms for collaboration and opportunity for a collective
impact approach for our region. GP collaborative activities to be undertaken by EMPHN include:
OP 2.1 Increase capacity for opportunistic screening in general practice and assess risk for STI in young
people through workforce supports co-designed with general practice and the EMPHN Clinical Council
OP 2.2 Develop STI Health Pathways for improving the patient journey where risk is identified or a
diagnosis made.
OP 2.3 Develop partnerships to promote STI screening in young people. Partnering with stakeholders
to provide youth promotion, and screening, including the piloting of a guide for youth sexual health
screening for general practice developed by Family Planning Victoria will add to the suite of support
activities aimed at improving screening rates.
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OP 2.4 Develop a deeper understanding of HIV infection in our region by working collaboratively with
key stakeholders to develop that understanding and establish its impact on chronic disease
management in relevant communities (particularly in key areas of Knox and Boroondara)
OP 2.5 Promote Hepatitis B and C screening in general practice by leveraging off cancer screening
work package (Activity 10.4) to promote hepatitis B & C screening in practices with relevant migrant
communities.
OP 2.6 Involvement in regional sexual and reproductive health initiatives. This will be supported
through developing a background paper in partnership with a Deakin student placement to support
advocacy for a national screening program for STI as part of the Eastern Region Sexual & Reproductive
Health Strategic Working Group
Internal support to General Practice and as enabler for Flexible Funded activity.
Collaboration regarding STI screening improvement activities to be undertaken with the following
groups:
Collaboration
Duration
•
•
•
•
•
•
•
Family Planning Victoria
Peak cancer bodies
Local Hospital Networks
PHN Alliance
Diverse Community Support Services
Department of Health (State/Federal)
Youth services and Headspace
Ongoing. Anticipated activity start and completion dates related to STI screening activities (excluding
the planning and procurement cycle) are:
OP 2.1 October 2016- June 2017
OP 2.2 January 2017 – May 2018
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OP 2.3 December 2016 – June 2018
OP 2.4 October 2017- June 2018
OP 2.5 April 2017 – June 2018 (as per 10.4)
OP 2.6 August 2016 – December 2017
Coverage
Entire PHN region, with STI activities to focus on key areas of Maroondah, Banyule, Boroondara and
Monash
What is the expected outcome of this activity as it relates to the PHN objectives?
Activities are expected to assist in achieving the following EMPHN Strategic Objectives:
1. Investment decisions are targeted for highest impact
2a. Consumers and providers (including GPs) are engaged
2b. Service needs are prioritized and identified gaps are filled
Expected Outcome
PHN objectives
providing practice support services so that GPs are better placed to provide care to patients
subsidised through the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS),
and help patients to avoid having to go to emergency departments or being admitted to hospital for
conditions that can be effectively managed outside of hospitals
Assist in the achievement of the following indicators of the Flexible Funded activities:
Local performance indicators specifically related to the STI activities and outside the process
outcomes related to areas requiring commissioning, which are explicated elsewhere in the document,
are:
OP 2.1 Increased notification rates of STIs (HIV, Chlamydia, Syphilis, Gonorrhoea and HPV) from
baseline due to increased screening by LGA and gender
OP 2.2 Health Pathways developed in line with recommendations from Family Planning Victoria
OP 2.3 Pilot conducted with Family Planning Victoria of the Guide for GPs once it is compiled by FPV
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OP 2.4 Scoping undertaken and co-developed recommendations for future action developed
OP 2.5 Hepatitis B and C notifications increase from baseline
OP 2.6 Annotated bibliography developed with Deakin University student and brief paper compiled.
Evaluation findings will be reviewed and reported.
Proposed general practice support activities
Activity Title / Reference (e.g. OP 1)
OP3: Digital Health/eHealth
eHealth is a key mechanism by which improvements in the primary health care system can be sought
by EMPHN.
The Digital Health Team has expertise to support the following activities relating to eHealth including:
Description of Activity
-
-
Supporting practices in the uptake of the ePIP
Increasing telehealth capacity in the region
Working in partnership with LHNs and Community Health in eReferral Projects
Internal Information Systems such as CRM and SharePoint that can be used for internal
information management and electronic platforms by which to share information with
Collaborative Platforms and Committees
Support for the roll out of My Health Record
Support for the roll out of the POLAR GP Clinical Audit Tool
The Digital Health team will support a range of internal teams and external organisations by providing
practical support and education to understand the processes and systems that underpin the delivery
of eHealth services in Australia. This team as the subject experts will build internal capacity and
engage directly with external organisations to assist them achieve the required eHealth objectives and
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provide the primary care interface to ensure a cross-system approach. Promotion and engagement
with key national infrastructure and service providers will be critical to enable the effective
deployment and expansion of eHealth initiatives across the EMPHN region.
This activity will assist general practices in understanding and making meaningful use of eHealth
systems, in order to streamline the flow of relevant patient information across the local health
provider community.
Whilst this program enables internal capacity across a range of activities, a specific activity in this
space will be undertaken in collaboration with:
Collaboration
eReferral: General Practice, LHNs – Eastern Health, Austin Health
Telehealth: General Practice, Specialists, LHN Outpatients/Specialists
Clinical Audit Tool: MEGPN, Gippsland and South East Melbourne PHN
Duration
Anticipated activity start and completion dates.
ePIP support: July 2016-June 2018
eReferral: July 2016 – June 2017
Telehealth: July 2016-June 2018
Clinical Audit Tool support: July 2016 -
Coverage
Entire PHN region
Expected Outcome
Activities are expected to assist in achieving the following EMPHN Strategic Objectives:
1. Leaders commit to system improvement
1c. Leadership and change capacity is enhanced
2. Investment decisions are targeted for highest impact
2a. Consumers and providers (including GPs) are engaged
3. Care processes designed for need and best use of resources
3a. Design and re-design occurs collaboratively
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3b. Services are reoriented to better meet needs
3c. Patients know where to go, when and why
3d. Effective, efficient services are procured
PHN objectives will be achieved by:
Providing practice support services so that GPs are better placed to provide care to patients
subsidised through the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS),
and help patients to avoid having to go to emergency departments or being admitted to hospital for
conditions that can be effectively managed outside of hospitals
A key metric to assist in improving service coordination across flexible activities includes:
All Public LHNs within the region and a minimum of 60% private hospitals registered for My Health
Record (2 years), 100% of PIP-registered general practices in the region registered and uploading to
MyHealthRecord, 100% of pharmacies with eHealth-capable software registered for MyHealthRecord,
100% of RACFs with eHealth-capable software registered for MyHealthRecord
This will be monitored internally through supports provided as currently the PHN does not have
access to a centralised listing of organisations registered to upload for My Health Record.
Proposed general practice support activities
Activity Title / Reference (e.g. OP 1)
OP4: Workforce Education & Clinical Placements
Description of Activity
The Workforce Education and Clinical Placement team aim to provide support and increase the
capacity of the primary care workforce through workforce development and education activities.
Workforce Development activities include:
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-
-
Clinical Placements to increase the capacity of the General Practice workforce through
attraction of medical graduates to the industry and build the supervisory capacity of General
Practice
General Practice (GP, Nurse, Practice Manager) Education through webinars and events
relating to areas of workforce development need
Primary Care Provider education to Pharmacy and Allied Health
International Medical Graduate preparation to increase General Practice workforce capacity
in outer metro areas
This aims to meet PHN objectives by providing practice support services so that GPs are better placed
to provide care to patients subsidised through the Medicare Benefits Schedule (MBS) and
Pharmaceutical Benefits Scheme (PBS), and help patients to avoid having to go to emergency
departments or being admitted to hospital for conditions that can be effectively managed outside of
hospitals.
Collaboration in the development and delivery of education with a range of organisations and services
includes at this time:
Collaboration
Delmont Private, Turning Point, Eastern Health, Peter MacCallum Cancer Institute, Monash Hospital,
and Royal Children’s Hospital.
Planning will be undertaken with key health organisations in line with identified priorities and related
activities that are flexibly funded.
Duration
Ongoing
Coverage
Entire PHN region
Expected Outcome
Activities are expected to assist in achieving the following EMPHN Strategic Objectives:
1. Leaders commit to system improvement
1c. Leadership and change capacity is enhanced
2. Investment decisions are targeted for highest impact
2a. Consumers and providers (including GPs) are engaged
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2b. Service needs are prioritized and identified gaps are filled
3. Care processes designed for need and best use of resources
3b. Services are reoriented to better meet needs
PHN objectives will be supported to be achieved
Providing practice support services so that GPs are better placed to provide care to patients
subsidised through the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS),
and help patients to avoid having to go to emergency departments or being admitted to hospital for
conditions that can be effectively managed outside of hospitals.
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After Hours Activity Work Plan
After Hours Activity Work Plan
46 | PHN Core Funding, PHN After Hours Funding
3. (a) Strategic Vision for After Hours
Funding
Please outline, in no more than 500 words, an overview of the PHN’s strategic vision for the
24 month period covering this Activity Work Plan that demonstrates how the PHN will achieve the
After Hours key objectives of:
•
increasing the efficiency and effectiveness of After Hours Primary Health Care for patients,
particularly those with limited access to Health Services; and
•
improving access to After Hours Primary Health Care through effective planning,
coordination and support for population based After Hours Primary Health Care.
In 2016-17 and onwards, your organisation is required to:
•
Implement innovative and locally-tailored solutions for after-hours services, based on
community need; and
•
Work to address gaps in after-hours service provision.
Our vision: Better primary healthcare for Eastern and North-Eastern Melbourne.
Our role: We facilitate primary care system improvement and redesign.
Our purpose: Better health outcomes. Better experience. Better system efficiency.
Our strategic objectives
4. Leaders commit to system improvement
1a. Joint forecasting and planning occurs
1b. Investment decisions are targeted for highest impact
1c. Leadership and change capacity is enhanced
5. Investment decisions are targeted for highest impact
2a. Consumers and providers (including GPs) are engaged
2b. Service needs are prioritized and identified gaps are filled
2c. Improvement proposals are based on best evidence
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47 | Eastern Melbourne PHN
6. Care processes designed for need and best use of resources
3a. Design and re-design occurs collaboratively
3b. Services are reoriented to better meet needs
3c. Patients know where to go, when and why
3d. Effective, efficient services are procured
Our values:
•
Leadership
•
Understanding
•
Collaboration
•
Outcomes
EMPHN Operating Model and the Commissioning Framework
In its role as a facilitator of primary care system improvement and redesign, EMPHN has adopted an
operating model made up of a continuous improvement approach to commissioning, and
governance structures geared towards collaboration and co-design.
Commissioning Framework
Commissioning is a cycle. Needs are assessed through community consultation and solutions are
designed in partnership with stakeholders. Transparent processes are used to promote the
implementation of these solutions, including the identification of providers from whom services may
be purchased. Solutions are then evaluated and the outcomes used to further assessment and
planning.
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48 | PHN Core Funding, PHN After Hours Funding
DRAFT
for discussion only
Our commissioning process
Activity
Establish stakeholders and targets for durable
improvements
Establish sequence of authorisation / permissions
and action these
Influence local system reform
Outputs
MOUs / agreements / authorisations
Project level documentation i.e., A3s
Activity
Quantitative evaluation against
metrics
Qualitative evaluation on
experiential factors
Embed
change
Translate / disseminate findings
Determine and recommend
adoption of new processes
Activity
Identify gap between current and
desired state
Confirm nature of problem (quality /
cost / flow)
Identify related issues & indicators
Determine characteristics / scope of
problem
Outputs
Problem
definition
Brief: scope / benefits / costs / timeline
Team structure: governance / sponsors
/ role
Project plan, including engagement /
measurement
Outputs
Activity
Evaluation reports
Evaluate
Future recommendations
Evidence publications
Diagnostics
Gather available data (demand /
capacity / consumer voice) and/or
develop data collection tools
Identify current state (process, issues /
waste)
Analyse issues (fishbone) and identify
root cause
Activity
Invite bids and evaluate
submissions against criteria
Deliver
Refine design with potential
providers
Select and contract providers
Outputs
Solution
Design
Current state map
Root cause analysis with hypotheses
(If x, then y)
Integrate local services / pathways
Outputs
Service delivery contracts
Care Pathways
Implementation reports
Performance reports
Activity
Understand sector landscape
Co-design service models / service improvements
Capacity building and sector development
Outputs
Commissioning
specifications
Core Functions are
to facilitate
Differentiation
Envisioning
with rigour
Analysing
Delivering
addressable
Effect
"what
& continuously
improve
Figure 1. Commissioning style
Underpinning the phases of the Commissioning Cycle is a focus on ongoing relationships
with consumers, providers and other stakeholders.
Figure 2. Prioritisation approach
49 | Eastern Melbourne PHN
Commissioning principles
12. Understand the needs of the community by
engaging and consulting with consumer, carer
and provider representatives, peak bodies,
community organisations and other funders.
13. Engage potential service providers well in
advance of commissioning new services.
14. Focus on outcomes rather than service
models or types of interventions.
15. A
dopt a whole of system approach to meeting
health needs and delivering improved health
outcomes.
19. E
nsure procurement and contracting processes
are transparent and fair, facilitating the
involvement of the broadest range of suppliers,
including alternative arrangements such as
consortia building where appropriate.
20. M
anage through relationships; work in
partnership, building connections at multiple
levels of partner organisations and facilitate
links between stakeholders.
21. Ensure efficiency and value for money.
22. M
onitor and evaluate through regular
performance reporting, consumer, community
and provider feedback and independent
evaluation.
16. Understand the fullest practical range of
providers including the contribution they
could make to delivering outcomes and
addressing market failures and gaps.
Consultative structures
17. C
o-design solutions; engage with stakeholders,
including consumer representatives, peak
bodies, community organisations, potential
providers and other funders to develop
outcome focused solutions.
• Clinical Council
18. Consider investing in the capacity of
providers and consumers, particularly
in relation to hard to reach groups.
50 | PHN Core Funding, PHN After Hours Funding
The EMPHN Board will receive strategic advice
on engagement and participation from to key
groups:
• Community Advisory Committee
Collaborative structures
Figure 2. Collaborative Structures
The EMPHN catchment will be divided into four
sub-catchments for the purposes of shared
planning and governance. The sub-catchments
will align with the large public health services
in the catchment:
• Austin Health
• Eastern Health
• Monash Health
• Northern Health
Each sub-catchment will have three levels
of collaborative structures:
Internal structures
The EMPHN organisational structure includes
programs that support and develop primary care
practitioners, and that support primary care
improvement and integration.
In addition to the formal governance structure,
EMPHN staff work across teams within specialty
area streams such as Indigenous Health, Aged
Care, Refugee Health and Mental Health.
EMPHN staff also work across teams to participate
in improvement and innovation initiatives.
4. G
overnance Group: Strategists who "direct
and authorise"
5. H
ealth System Integration Group: Managers
who "align and allocate resources"
6. P
riority Working Groups: Content experts
who "connect with end users and implement"
51 | Eastern Melbourne PHN
3(b) Planned activities funded by the Primary Health
Network Schedule for After Hours Funding
PHNs must use the table below to outline the activities proposed to be undertaken within the period 2016-18. These activities will be funded under the
Primary Health Networks After Hours Funding.
Note 1: Please copy and complete the table as many times as necessary to report on each activity.
Note 2: Indicate within the duration section of the table if the activity relates to a two year period (2016-2018) or a one year period (2016-2017). Please
note, although PHNs can plan for activities in the 2017-18 financial year, at this stage, current funding for PHNs After Hours is confirmed until 30 June 2017
only. PHNs must not commit to any part of the funding beyond 30 June 2017.
Proposed Activities
After Hours
Priority Area 1
Limited access to GPs and other primary health care services in the after-hours period
After Hours Activity
Title / Reference (e.g.
AH 1.1)
AH 1.1 Expansion and development of
new service models for the delivery of
Medical Services in areas not currently
serviced by a MDS.
Description of After
Hours Activity
•
Commission an expansion of
Medical Deputising Service
AH 1.2 Support the continuation of afterhours GP clinics in the outer north and
outer east of the region, where there are
limited or no MDS services available.
•
Support current after hours GP
clinics to continue, and expand
AH 1.3 Determine demand and
availability of ancillary services such
as Radiology and Pathology during
the after-hours period, and
commission additional after hours
services where appropriate.
• Comprehensive mapping the
availability of After Hours
Radiology and Pathology
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52 | Eastern Melbourne PHN
•
•
Collaboration
Duration
(MDS) beyond the current MDS
delivery boundaries.
Scope a new service delivery
model (to be developed) in
areas where MDS do not
operate
In suburbs bordering other
PHNs such as the Dandenong
Ranges a joint collaboration will
be developed with South
Eastern Melbourne PHN. The
key partners for the service may
include current MDS and/or
General Practice.
12 months
•
Coverage
•
Commissioning
approach
•
hours to meet community demand if
required.
Work with the identified clinics to ensure
service continuity.
services, complete cost
benefit analysis and
commission additional
services where required with
a focus on RACFs. Explore
mobile options that can
attend the patient’s bedside.
(* see below)
•
Possible partners include:
•
•
•
Local GP Practices
Local Hospital Network
Community Health Service
Collaboration with ancillary
services, General Practice,
Hospital Networks and MDS
services.
(*) A comprehensive business review was conducted in
March 2016 in readiness for commissioning process
12 months
Outer East including LGAs of
Yarra Ranges
Outer North including LGAs of
Whittlesea, Murrindindi,
Mitchell, Nillumbik
•
The commissioning process will
involve direct engagement with
MDS and General Practice
•
Catchment wide but specifically
targeting areas of identified need.
The commissioning process will
involve an approach to market
method. The development and
12 months
•
EMPHN Catchment
•
The commissioning process
will involve an approach to
market method.
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53 | Eastern Melbourne PHN
where a Request for Tender
(RFT) will be developed and
consequently advertised. The
RFT will include regular
reporting requirements.
•
•
Performance Indicator
•
•
•
•
•
MDS Service Delivery Reporting
including Minimum Data set
Included in the contract.
Minimum Data set includes
DOB, Suburb,
Indigenous status, Primary GP,
reason for referral and outcome
of consultation
Level of engagement and
participation with young
families in the Yarra Ranges.
Securing an MDS to participate
in the pilot project
MDS service delivery reporting,
rates of service delivery and
fluctuations.
Number of families
participating in the pilot
Number of telehealth sessions
completed.
Level of satisfaction in the
service delivery from both
families and MDS service.
continuation of services has been
progressing and stakeholder
engagement will continue to ensure
an appropriate After Hours model of
care is implemented at all sites.
•
•
•
•
•
•
•
Reported opening hours outlining
consistency and availability of the
service, and if there are workforce
shortages
Patient throughput indicating the
need/demand for the service from
the community
The number of patients reported to
be diverted from the Emergency
Department
The number of patients referred on
to additional services such as X Ray
and Specialists.
The number of low cost after hours
services available, baseline and
variation over a 12 month period.
Analysis of age, gender, ATSI, CALD
and refugee status.
Outcomes to be determined when
fully scoped
•
•
•
Reduction in ED Admissions
(VMED data) for conditions
requiring routine Pathology
and Radiology
To be determined once fully
scoped.
Outcomes to be determined
when fully scoped
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•
•
•
Local Performance
Indicator target
Data source
•
Measures for new service
delivery model will be
progressed when the service
model is further developed
Outcomes to be determined
when fully scoped
Target of 1200 consultations by
MDS to the areas of the region
without MDS coverage.
Access to timely out of hours
medical care for 95% of
EMPHN population
•
•
Supporting a minimum of three
clinics to deliver after hours services
across the region
Increasing the number of patients
attending the after hours clinics by
5%
•
To be determined when
scoped
Contract reporting
Contract reporting
Contract reporting
Victorian Emergency Minimum Data
(VEMD)
Victorian Emergency Minimum Data set
Victorian Emergency Minimum Data
set
MDS Minimum Data set
Community awareness strategy
Contract Reporting
Evaluation framework
Community engagement/awareness strategy
To be determined
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Proposed Activities
After Hours
Priority Area 2
Limited RACF access to GPs and other primary health care services in the after-hours period
After Hours Activity
Title / Reference
(e.g. AH 1.1)
AH 2.1 Continuation of the After
Hours Visiting GP Service to outer
east and north RACFs, and complete a
scoping exercise and pilot for in hours
model of care utilising MDS to
provide more timely access to GP
services in RACFs.
•
Description of After
Hours Activity
•
•
Collaboration
Continuation of the Medical
Deputing Service – Visiting GP,
to provide After Hours Care in
RACFs where there is
currently minimal or no MDS
services available.
Complete a scoping exercise
and pilot an “in hours model
of care” utilising General
Practice to address issues
prior to the after-hours period
and reduce after hours
presentations to ED.
Collaboration between MDS,
General Practice, Community
Health Services, RACFs
AH 2.2 Expansion of Hospital based
Residential In Reach Program, and deliver
Training to RACF Staff via the Residential In
Reach programs
•
•
Support the provision of RIR services
in the after-hours for RACFs with
access to high quality, multidiscipline care through the
Residential In Reach Services
operating in the region. Expand the
service where an identified need.
Commission Local Hospital Networks
to provide a targeted education
campaign for RACFs focussing on
hospital avoidance related medical
conditions
Collaboration with some of the Hospital
Networks within the EMPHN Catchment
including;
•
Eastern Health
AH 2.3 RACF De -prescribing Project
•
Commission Hospital Network to
work with RACFs to identify and
reduce polypharmacy in RACFs
Collaboration with some of the Hospital
Networks and the PHN within the
Northern Part of the EMPHN Catchment
including;
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56 | Eastern Melbourne PHN
•
•
•
•
Duration
Northern Health
St Vincent’s Hospital
Austin Health
Southern Health
Northern Health
St Vincent’s
Austin Health
North West Melbourne PHN
12 months
12 months
12 months
Outer East including the suburbs of:
EMPHN Catchment wide
LGAs including:
•
Montrose, Lilydale
Healesville, Yarra Junction,
Warburton
Outer North Suburbs of:
Coverage
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Whittlesea
Melbourne
Banyule
Nillumbik
•
The commissioning process will
involve direct engagement with
the Hospital Networks.
Epping
Mill Park
South Morang
Thomastown
Eltham
Whittlesea
St Helena
Scoping exercise and pilot will focus
RACFs with high rates of ED transfer
for cat 4 and 5 in the after-hours
period.
Commissioning
approach
•
The commissioning process
will involve direct engagement
with MDS and General
Practice where a Request for
•
The commissioning process will
involve direct engagement with the
Hospital Networks following
consultation to determine gaps in
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57 | Eastern Melbourne PHN
•
•
•
•
Performance
Indicator
Tender (RFT) will be
developed and consequently
advertised.
The contract will include
regular reporting
requirements.
MDS Service Delivery
Reporting including Minimum
Data set
Deliverables as outlined in the
contract
Engagement with RACFs and
MDS services to deliver the Inhours MDS pilot
•
•
•
•
•
•
Local Performance
Indicator target
•
•
MDS reporting data
Incidence rate of issues
addressed in hours at RACFs
To be determined
•
•
the areas of service in the after
hours.
The commissioning process will
involve direct engagement with the
Hospital Networks.
A contract will be developed
following identification of the topics
and method for the targeted
education program.
After Hours Consultations conducted
by RIR, and hours of additional RIR
service delivery
Review of ED Presentations and RIR
attendance data from Eastern
Health, Austin Health and Northern
Health to harmonise collection of
data and review common
presentations to target in education
sessions as outlined in the Contract.
Number and type of education
sessions delivered by the RIR
services
Evaluation of both the service
delivery and education delivery by
RIR
12 education modules developed.
12 education sessions conducted
with RACFS and MDS, and a
minimum of 10 attendees per
session
•
The contract will include
deliverables outlining number of
reviews conduct, effects of
intervention and evaluation
•
Number of comprehensive
Resident Medication
Management Reviews
conducted (RMMR)
Reaudit residential files that
receive RMMR
Completion of educational
component at RACFs
Review of ED Data pre and post
intervention
•
•
•
•
Engage 10 facilities in the
project
•
100% of resident medication
charts audited with a succinct,
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58 | Eastern Melbourne PHN
Contract reporting
Contract reporting
evidence-based, initial screening
tool
• Those identified as being ‘high
risk’ will be referred for a
comprehensive RMMR
• Those residents receiving the
RMMR will have their
medication appropriately
rationalised to improve quality
of life and prevent complications
• Improved GP awareness of
polypharmacy and subsequent
prescribing behavior
• RACF nursing staff awareness
will be increased through
targeted education sessions
regarding the impacts of
polypharmacy
Contract reporting
Victorian Emergency Minimum Data
(VEMD)
Victorian Emergency Minimum Data (VEMD)
Project evaluation framework
•
•
Data source
MDS Minimum Data set
Pilot evaluation framework
Reduction in ED presentations
through a Retrospective review and
post intervention ED Dataset
Funded hours for RIR services
matches demand.
Education evaluation framework
Australian Atlas of Healthcare Variation,
November 2015
Community awareness strategy MDS
Data Set
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Proposed Activities
After Hours
Priority Area 3
Increase quality and capacity of after-hours primary health care services
AH 3.1 Quality Service provided by
After Hours Activity Title / MDS, GPS and RACF Staff,
including upskilling in Emergency
Reference (e.g. AH 1.1)
Decision Making.
•
Description of After
Hours Activity
•
•
Provide education and
support to General
Practice, locum Doctors
and RACF Staff on
delivering a primary care
response to identified
clinical issues in the After
Hours period.
Assist RACFs, MDS and
General Practice to
Implement emergency
decision making guidelines
at RACFs
Promotion of Diversional
and substitution programs
such as Hospital
Admissions Risk Program,
AH 3.2 Extension of Pharmacy
Opening hours in the afterhours period
•
•
Target and work with
pharmacies to expand
their operating hours in
areas of identified need.
Provide support to
pharmacies to enable
the provision of after
hours medications to
RACFs.
AH 3.3 Targeted Grants
Program
•
Implementation of a
grants program to
maximise after -hours
primary carel service
availability to support
the community
AH 3.4 Improve quality
of information
provided on the NHSD
•
Implement a
project to assist
General
Practices to
update service
information on
the NHSD on a
regular basis.
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Collaboration
Duration
Hospital in the Home and
RIR
• A collaboration with LHN,
General Practice, MDS and
RACFs to implement
educational programs
including emergency
decision making training.
12 months
Collaborate with local
pharmacies in areas of
need, including GPs,
RACFs, and the general
community.
•
Collaborate with local
GP Practices and
Community Health
Services
•
Collaborate
with local GP
Practices
12 months
12 months
12 months
Across EMPHN Catchment
Selected areas within the
catchment
Selected areas within the
catchment
Catchment wide
Direct engagement
Direct Engagement
Direct Engagement
Direct engagement
Coverage
Commissioning approach
Procurement approach to be
determined
•
Performance Indicator
•
TBD
•
•
Number of additional
hours open between
baseline at the
commencement of the
project and at the end
of the project
Additional services
provided in the 24hr
period it is open
•
•
Grant process
completed include the
development of
successful application
criteria.
Approved grants
illustrate value for
money, diversity,
sustainability , focus
on particular
population groups and
demonstrate a
•
•
•
•
Establishment
and
implementation
of pilot project.
Upload
guidelines
developed
Up take of
program
Audit of
information on
the NHSD pre
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61 | Eastern Melbourne PHN
•
•
Local Performance
Indicator target
•
Implementation of an
awareness strategy about
diversional programs and
services. Review of skill set
improvement for
participants.
Number of education
sessions completed as per
the project plan. Feedback
from educational sessions.
Pre and post educational session
Data source
VEMD 2014-15
•
An increase in the
number of opening
hours in the After Hours
period across the
EMPHN catchment.
•
reduction in ED
admissions.
Grants approved meet
deliverables as
outlined in contract
An increase in the
number of opening
hours in the After
Hours period across
the EMPHN
catchment.
and post
intervention
•
•
Contract Reporting
Contract Reporting
VEMD Data
80% of Practices
are aware of
the procedure
for uploading
information to
the NHSD
Increased
accuracy of
information
provided on the
NHSD website.
NHSD Pilot Project
Report
Australian Atlas of Health Care
Variation, 2015
Proposed Activities
After Hours
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62 | Eastern Melbourne PHN
Priority Area 4
Increased community awareness of after hours services and options
After Hours Activity Title
/ Reference (e.g. AH 1.1)
AH 4.1 Plan and deliver a catchment-wide community education campaign and completion of a health literacy study
Plan and deliver a catchment wide community education campaign to inform the community of all available after hours
services, through the following activities:
•
•
•
Description of After
Hours Activity
•
•
•
Collaboration
Development of resources both paper and digital based to be disseminated to relevant community and health
organisations. It is anticipated that a comprehensive digital campaign will include e- billboards, television commercial
CSA and app.
Collaboration with other metropolitan PHNS to deliver a metro wide media campaign
Deliver the after hours messaging in languages other than English, and with culturally engaging design and
resources. Develop a model for the delivery of information on after hours care options in all Emergency
Departments. Where data indicates a high number of primary care type presentations, EMPHN will work with the
identified Hospital to develop the most appropriate communication tool to provide information to the community
on alternative afterhours options.
Develop sub-strategy for particular catchments within the PHN for ATSI, paediatric and CALD populations, and regions
that do not have access to MDS
Health Literacy study by sub population to focus on a designated cohort to assess individual’s knowledge, skill and
confidence for managing their own health and healthcare. Following the study, implement recommendations
developed.
Complete a comprehensive evaluation of the communications strategy including obtaining data from sources such as
health direct, google analytics and the community pre and post campaign to identify the effect on a reduction in
primary care types to emergency department. A number of community consultation sessions and focus groups will
be conducted to determine the impact of the community awareness campaign.
Incorporate consultation with relevant stakeholders including Community Groups. Potential collaboration with University to
conduct trial and evaluation.
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63 | Eastern Melbourne PHN
Metropolitan wide PHN Strategy collaboration with other PHNs
Duration
12months
Coverage
Entire EMPHN Catchment
Commissioning approach
Direct Engagement Approach as well as Approach to Market for design and printing of marketing material
Performance Indicator
Develop of a region wide Communications Strategy Review of NHSD data
Evaluation of Communications Strategy through the following data sources:
Local Performance
Indicator target
•
•
•
•
Proportion of Primary Care Type ED Presentations referred by Nurse on Call, GP Helpline/MDS
Portion of calls to Nurse on Call and GP Helpline in the After Hours Period from people within the EMPHN catchment
Development and distribution of Materials
Qualitative and Quantitative Survey (telephone) examining reach and comprehension of messaging.
Health Literacy study recommendations.
Review of NHSD data
Contract reporting ie through evaluation of information sessions
Data source
ABS (2006) Health Literacy, Australia; ABS (2011) Proficiency in Spoken English (ENGP)
Health Literacy Project Evaluation
Proposed Activities
After Hours
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64 | Eastern Melbourne PHN
Priority Area 5
Culturally safe and accessible primary health care services for Aboriginal and Torres Strait Islander, and CALD and Refugee people
After Hours Activity
Title / Reference (e.g.
AH 1.1)
AH 5.1 improve access of after-hours primary care for
CALD communities
Work with culturally and linguistically diverse
community leaders/representatives to design
community initiated strategies that will improve
access to after-hours primary care.
• Build workforce capacity to enable more people to
work with CALD communities in the after hours
• Collaboration with the EMPHN, GPs, MDS and
CALD services including Migrant Information
Centre, Spectrum Migrant Resource Centre and
Community Health Services
12 months
•
Description of After
Hours Activity
Collaboration
Duration
Coverage
Commissioning
approach
Performance Indicator
EMPHN Catchment
AH 5.2 Explore the viability of transportation support services to
after-hours clinics for vulnerable populations
•
Explore the viability of transportation support services such
as extending volunteer transportation services after hours
or trialling reimbursements for taxi-based transportation to
certain after hours clinic for vulnerable groups.
•
Collaboration with Local Government GPs and Primary
Health Care Organisations
12 months
Outer East and Outer North suburbs located in the LGA of Yarra
Ranges, Nillumbik and Whittlesea
•
Direct Engagement with key stakeholders and GPs
•
Direct engagement with relevant organisations.
•
Key Strategies developed in conjunction with
consultation from relevant stakeholders.
Development of relevant activities which include
deliverables as outlined in contract.
•
Identification of factors affecting access to after-hours
services
Baseline: Number of potential clients who could utilise
service
•
•
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65 | Eastern Melbourne PHN
•
Local Performance
Indicator target
•
•
Data source
•
•
•
Implementation of projects designed to incorporate
identified strategies.
Development of a set of key priorities to address
identified issues
Increased available workforce and additional points
for referral
Project Reporting template
ABS Socioeconomic Indices for Area
ABS (2006) Health Literacy, Australia; ABS (2011)
Proficiency in Spoken English (ENGP)
•
Increased number of patients attending After Hours Clinic
because of increased access to Service
•
VAED via Polar
Proposed Activities
After Hours Priority Area 6
Increased access to mental health services in the after hours period
AH 6.1 Increased access to After Hours
mental health care for young people
After Hours Activity Title /
Reference (e.g. AH 1.1)
Work with the EMPHN mental health team
to improve the service system in the After
Hours
AH 6.2 Improve the capacity of
GPs and MDS to provide mental
health services in the After
Hours
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66 | Eastern Melbourne PHN
•
•
Description of After Hours Activity
•
Work with community health
services and youth-friendly GP
services to increase access to after
hours services for youth
Work with the EMPHN mental
health team to improve the service
system response for residents
experiencing mental health issues
after hours.
Determine best strategies for
integrated co-located After Hours
Mental health services
•
•
•
Scoping project to
determine current
services available after
hours.
Explore viability and if
appropriate, trial a
mental health advice line
for use after hours for
General Practice and
MDS .
Improve capacity for MDS
to provide quality After
Hours Mental health care
by providing Mental
Health training
Collaboration
Collaboration with GPs and key mental
health agencies
Collaboration internally and with external
stakeholders
Collaboration with Mental Health
Organisations such as Headspace,
MIND, Community Mental Health
Services and Beyond Blue
Duration
12 months
12 months trial
Coverage
Across the EMPHN Catchment
Across the EMPHN catchment
•
Commissioning approach
Direct engagement with key
stakeholders and community groups
•
Approach to Market to
implement telephone
response system.
Evaluation completed by
the EMPHN.
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67 | Eastern Melbourne PHN
•
Performance Indicator
Establishment of a working party to
address access to mental health
services in the After Hours, in
particularly integrated co-located
After Hours Mental health services.
Resulting in a geographic shift of
services into areas that experience
the greatest barrier to access
•
•
•
•
Local Performance Indicator target
•
•
Data source
Development of a number of
recommendations to improve access
to mental health for young people in
the After Hours
Geospatial mapping of services with
areas of need overlay
Eastern Metropolitan Region
Mental, Drug and Alcohol and Drugs
Catchment Planning Report
•
•
•
Trial health professional
mental health phone line,
established, operating
and evaluated
Contract Deliverables
met
Dataset detailing target
group, gender, age
utilising the system,
GP/MDS Usage data
Evaluation of training
provided
GPs and MDS report
more appropriate access
and reduced wait times
for services
Psychological distress
indicator data (PHIDU)
69
68 | Eastern Melbourne PHN
FOR MORE INFORMATION
18-20 Prospect Street (PO Box 610) Box Hill, Vic 3128
69 | PHN Core Funding, PHN After Hours Funding
Phone 9046 0300
www.emphn.org.au